Psyched Out

Mary

Master's of Social work student and excellent editor. I suffer from adrenal insufficiency following thirty years of prednisone and want to research how many asthmatics in my generation are undiagnosed or misdiagnosed. I'm also a professional editor.

It started out with getting to that serious muscle pain that tells you to quit exercising about ten minutes earlier than usual in my daily workout. I figured I was just pushing myself a little harder than usual. But gradually my workouts got to that pain point sooner and sooner. After 8 or 9 months I just couldn't tolerate it anymore, but I thought it might just be age or something (I was only 38!). It kept getting worse, but I ignored it - I had a more than full time social work job and four year old twins, so the exhaustion seemed understandable. I felt lazy. I was tested for sleep apnea, but didn't have it.

Then one day I couldn't finish grocery shopping, even though I already knew where every resting place in the store was. I sat there crying, feeling like if I took one more step or even stayed standing, I would fall down. I knew there was something seriously wrong that day.

The next time I went shopping, I broke down and used a mobility cart. I felt humiliated, like everyone was staring at me. And I did get glares - I *looked* perfectly healthy but fat. (Now I glare right back - fat people get disabilities too!)

I decided to tell my doctor about the exhaustion again. He suggested we adjust my asthma meds, assuming it was low oxygen levels. A month went by, no change.

For the next 3 years I went to specialists, got tests that all came out normal, and kept getting worse and worse. The thing I kept trying to explain was that I didn't START OUT exhausted, I started with and rapidly regained my usual high energy level. The time between healthy energy and excruciating muscle pain with exhaustion that made me sit down on the floor even in public places got shorter and shorter.

About 2.5 years in, I started having severe muscle pain the day AFTER exertion, just as if I'd been carrying heavy boxes or running 5K's the day before. By 3 years I couldn't stand long enough to sautee mushrooms or take a normal shower. It was (IS) very hard to manage my limited energy because I start out feeling fairly energetic, but quickly tire with minimal exertion.

I switched psych meds in case that was the cause, and lost 40 # in 4 months. I was constantly hot and started sweating a ton, and I have NEVER sweated much. I started eating salt and vinegar chips like they were going out of style and salting my food, which I'd never done - I usually hate salt. I started having excruciating abdominal pain and got my gall bladder out last fall. It took me six weeks to recover from laproscopic surgery, instead of the promised 3 days.

This spring we bought an electric can opener because I would drop the manual one when the burning muscle pain MADE me after a few rotations. My exhaustion level would reach a point I'd only experienced when I'd actually been dying from asthma attacks as a child.

Nobody knew what was happening to me. I was terrified that I was going to die without anyone knowing.

I requested a referral to an endocrinologist, and went to Dr. K who immediately knew that it was SAI when she heard about my 30 years on high dose prednisone and Post Traumatic Stress Disorder from childhood. I also have the classic fat deposit from steroid use called a "buffalo hump." (And seriously, would it KILL them to just say "fat deposit"?) She ordered a bone scan and vit D level, which was 5 out of 60. My bones are fine, thankfully.

Taking steroids isn't an option because they CAUSED the SAI in the first place. Also, because last time I took them I got steroid psychosis. But I can get the vitamin D up where it should be, so I'm concentrating on that. Then I can start the long road toward rebuilding my muscles.

Back in the 1990's, before Ed and I were married, I had an unplanned possible pregnancy. This would be distressing at any time, but I had a neck level spinal injury and my doctors said I couldn't carry a pregnancy without quadriplegia or death resulting. My fiance Ed and I naturally intended to adopt.

Our condom broke in North Carolina Sunday Night, and the Planned Parenthood there was closed. Uninsured, I had no way to pay for a $500 Emergency Room visit. So I had to fly back to Chicago, drive back to Iowa and wait for Student Health to open. Every hour until I could take emergency contraception - called Plan B now and over the counter - meant it was less likely to work. There's a 72 hour window.

I felt so many conflicting emotions. Of course I wanted a baby from the man I loved, and ending the pregnancy felt tragic, so much so that I considered continuing it and taking the risks. Ed and my best friends talked me out of it, but I remained ambivalent emotionally, though not intellectually.

I've always been passionately pro choice, because minority religious beliefs shouldn't enter into medical care. Lots of Christians think that dancing, music, swearing, celebrating holidays, studying science, going to the doctor and playing cards are sinful and should be illegal. I respect their right to their beliefs and practices, but don't believe they have the right to make those activities federally illegal when they are free to abstain from those activities in this country. If they don't want to have abortions nobody will force them. And nobody could force me either way, I was the only one who could decide - entirely appropriate, it is MY body! Now I understood better why anti-abortion and anti- birth control people feel the way they do.

At hour 51, I took Plan B's first pills, knowing they might not work. I wanted Ed's baby inside me. I wanted to stay alive and healthy.

The hormone pills made me even MORE emotional, and I stayed with my friends until the hormone hurricane was over and I could take a pregnancy test. It was negative, as were later tests. Failing tests was actually a relief.

As a person who occasionally depends on doctors to save my life, I would prefer that they were required to demonstrate prior to med school admission:

1. An aptitude for UNDERSTANDING medical and scientific research. I really couldn't care less if they are brilliant scientists themselves. I sure as shit don't care if they're good at physics. I want them to know that epidemiology can never establish causation. Correlation does not establish causation. Period. Ever.

I want them to know they need to read their journals weekly, and that they can't rely on the authors' conclusions but need to read the WHOLE paper and draw their own conclusions. The ability to understand basic genetics and MZ vs. DZ twin vs. parental concordance is needed. Knowledge of the relative scientific strengths and weaknesses of quantitative and qualitative research should be firmly in place as well. With rare or currently untreatable illnesses, and even healthy conditions like pregnancy where you can't just randomly assign treatment and no-treatment groups, following a population clinically is both ethical and informative.

2. An ability to LISTEN to what patients say and what they don't say, and draw correct conclusions then check with the patient (and witnesses) to clarify. This can be done in seconds in an emergency. A couple of social work courses in assessment would instill this critical ability.

3. A basic understanding of human psychology, including but not limited to: human developmental stages; motivated behaviors (thirst, sleep, hunger, breathing, pain, pleasure) that are not under a person's control; a class on the biological basis of addiction (neurologically similar to epilepsy) as opposed to psychological dependence (which happens equally with marijuana, hugs, and asthma inhalers), and last but not least the common mental illnesses.

5. While we're at it, how about a grounding in health (including pregnancy) on which to build a separate and parallel knowledge of pathology. I want doctors to recognize the natural variation in human phenotypes, and the effects that harsh or oppressive environments have on individuals and groups over time.

6. Economics, including a thorough review of the cost of treatment and medication compared to the typical income levels of different populations, so that they will not label poor people "non-compliant".

7. Ethics - so that when they see other doctors abusing or butchering patients, they REPORT them to the police. And so when they are having trouble themselves, they seek help instead of harming patients and relying on other doctors to cover for them.

8. A medical history class detailing health and science fads that are still with us today. Positive fads are important, but aversion fads are critical to understanding that one's own biases can cloud clinical and scientific reasoning.

I'd rather be treated by an English Literature BA or Auto Mechanics AD with those skills than a double major Biochem/Physics undergrad without them. It amounts to ten undergraduate classes at the most, only two semesters even for relative slackers.

And while we're at it, I want working interns, residents and attendings to get at least 8 hours of sleep in 24. I've nearly been killed by doctors who were so sleepy they couldn't have counted to ten if asked. Fortunately, either nurses took over and TOLD the comatose docs what to do, or I was an asshole and demanded a doctor who was competent to make legal decisions, let alone diagnoses and treatment decisions. How can people emerge from even a basic biology class without understanding that humans need sleep?

15 minutes into this movie, my slender son walked out of this movie in disgust and anger. "This movie is too mean to fat people!" See, almost all of the people he loves best, including his twin, are fat. Now, there absolutely are funny fat jokes, and those were the ones shown in the preview. Air vent breaking because of fat guy inside - not funny. Fat guy deliberately breaking air vent using his weight to crush mall "terrorists" - hilarious, comedy gold. Even for people the actor's size. I can go to the pool and hear fat people being made fun of, snarked about and hated on. Why should I pay for it?

The breaking point was when bystanders were all "ewww" when they saw a fat woman's stomach during the first fight scene. Seriously. A two for one sale on "fat people are disgusting and untouchable" and "thoughtless, senseless misogyny sold here!"

What should properly be seen as disgusting is the "forty-plus guy falls for girl a few years older than his middle schooler daughter." Creepy. If she were a clinically underweight but lovely thirty year old he fell for and pursued with borderline stalking methods that worked, whoo hoo, good for them. But when it's a teenager, not so much.

Now, I really did want to see this movie due to the actually funny physical comedy in the previews I saw. And I might have been willing to sit through the hateful jokes for the good ones on my own. But when there's too much hate for my 8 year old twins and ther 7 year old friend in the first fifteen minutes, I won't give the producers my money again. As we walked to the parking lot, my daughter K's (slender) friend M complained about how much she is teased for playing with (let alone being best friends with!) a fat girl. K (European American) isn't teased by other kids for befriending M, an African American girl. I'm just sayin'. (And no, this does not mean that fatphobia is the Last Acceptable Prejudice. It's just one reason we deliberately live in a diverse white-flight neighborhood.)

So this sewer rat might taste like pumpkin pie at the end, but I'll never know.

I saw an awesome Rheumatologist who does NOT think that this is lupus, or fibromyalgia or any other specific autoimmune illness that is destined to worsen, but "adrenal fatigue" from being on steroids for thirty years, worsened by the cortisol output from trauma/PTSD reactions. She described it as "tug of war" on my immune system, and basically agreed with the neurologists that it's a clinical picture they often see in long term steroid takers. I certainly don't regret the steroids - I'm alive to complain about pain, after all! Seems like a pretty fair trade to me. :)

Dr. Keys is the first non-psychiatrist I've ever had who even KNEW about the trauma-cortisol link, let alone took a PTSD diagnosis as meaning anything other than "she's probably just imagining things" or "of course she's casting herself as some sort of medical victim" or just "batshit crazy, must be all in her head or an attempt to score narcotics." Plus I was seriously Vitamin D deficient and was prescribed Vit D, and calcium supplements to protect against osteoporosis in my arms - weight is extremely protective for feet, legs and spine because weight bearing exercise is protective no matter how it is acquired. Also, she said not to worry about weight, just eat a variety of foods and exercise like I always have.

Health At Every Size is gaining popularity with Dr.s who read the research - half of people are fit, no weight differences in that. Even the heaviest fit fat people have better health and live longer than unfit "ideal weight" people. (And "overweight" people live longest and are healthiest of all the weight groups. "Ideal weight" people come next, and underweight and obese people trail mildly.)

Gender is a much more important lifespan factor - women are sicker but live over a decade longer on average. Men have fewer illnesses, but those illnesses tend to come late in life and be acute and short rather than chronic and long. There's some thought that chronic illness might even be protective, but it's not established and we really have no idea why women live longer. And yet there's no "War on Maleness" and we don't advise men to have sex reassignment surgery to improve their health, the way some people are convinced to have their stomach and intestines mostly cut out so they can't absorb nutrients and will lose weight. I'm not convinced by the science that it's any more rational. :)

MEDICALCarrie's medical history is minimal by her report, despite a ten plus year substance abuse history and domestic violence until her "after her first child was born." which would seem to imply that her husband physically abused her during pregnancy. She is not forthcoming with medical history details such as whether she practices safe sex when high or uses nicotine. She does not report taking any medication or practicing birth control methods of any kind. Carrie will be referred to a medical doctor for a gynecological exam to rule out AIDS and other STDs as well as cervical cancer potentiated by them. Weight is also an immediate concern - Carrie is severely underweight, only 3 pounds over the anorexia diagnostic level. Weight instability through rapid losses and cycling due to crack use may put her at risk for medical problems, although she reports no weight-associated illnesses in her family history or personal health indicators. Carrie reports that when she uses crack she simply has no appetite and does not eat. She reports no history of otherwise disordered eating. Carrie says that she experiences withdrawal symptoms from crack cocaine use, and her moodiness and jitters are evident. She has a history of blackouts from alcohol beginning at age 16, nine years ago. Crack withdrawal causes her labile mood and shakes, but cardiac effects of withdrawal are not always as evident in women as men. I have referred her to a local gynecologist for a medical examination. Carrie appears willing to seek medical care and take any prescribed medications while in our program.

PSYCHIATRICGeneral Observations: Carrie presents today with excellent self care but quiet and withdrawn demeanor. She avoids eye contact and is only getting the treatment she needs because her husband threatened to call CPS on her for neglect of their two children. Her memory, insight and orientation are intact and she poses no immediate danger to herself or others. Carrie gives the overall impression of numb, overwhelmed mood and poor insight into or denial of the serious nature of her substance abuse. She appears shocked, and agrees to my recommendation for inpatient treatment, when we explore how her children could be harmed if she is too intoxicated or crashed to respond to an emergency in the night. Carrie gives a "mild" trauma history of a forced abortion at age sixteen and domestic violence in her marriage, which she minimizes. Carrie reports that she has never had counseling or attended NA or AA, so we have arranged a beginning in her first residential substance abuse program: individual, group, and family available might raise her self esteem, helping the domestic issues.

We plan to provide individual outpatient treatment following her inpatient program, and Carrie feels that this will be adequate. Mood symptoms will be monitored by staff due to the link between depression and substance abuse or dependence, especially crack cocaine. There seems to be no need for a psychiatric referral, but inpatient will monitor symptoms. Carrie appears to have subclinical problems in several areas: mood disturbance, dangerously low (nearly anorexic level) .weight with risky weight cycling due to substance abuse. Formal psychiatric treatment is deferred at this time, but will be reconsidered should the depressive mood prove disruptive to Carrie's substance abuse treatment. If she is diagnosed with depression or another psychiatric illness, Carrie indicates a willingness to take medication if recommended by the physician.

SUBSTANCE ABUSE Carrie reports that she started drinking as a young adolescent, and snorted cocaine only after she married into wealth. Her report today was enough data to diagnose her with Cocaine Dependence. She had been using cocaine daily for six months, and is visibly experiencing cocaine withdrawal after two days clean with obvious jitters, moodiness and general malaise. She reports use triggers being the kids' behavior, high stress and being at family parties with alcohol. Carrie has tried several times to quit on her own without success. Carrie experienced her first alcohol blackout at age 16 following a forced abortion. Carrie noted heavy alcohol and drug abuse in several generations of her family of origin. Carrie's social roles and functioning have been seriously impaired by her substance abuse: she is neglecting her children, prostituting herself for cocaine and having affairs, there is hostility and tension in her marriage, and her use as a teen cut off her schooling and she has no GED and virtually no job experience as a result. Carrie realized for the first time the potential of hurting her children by using heavily after they are asleep. She consents to attend our residential treatment program for the 30 days her insurance covers. We agree that she will try the very intensive residential treatment first, re-entering this individual program afterward for further intervention. She has private insurance that will cover part of the residential treatment, and the family agrees to self pay for 16 days of inpatient treatment.

FAMLY & SOCIALCarrie tells me that she is the middle sister of three, with no brothers. She felt sibling rivalry keenly and acted out with substance abuse and sex from early adolescence to get attention from her parents. Carrie's family is distant at this time, but not intensely hostile. However, she must attend "raucous parties" with drug and alcohol use rampant to get any time with her family at all when they come to New Jersey twice annually. They will not forsake the parties to visit with Carrie. Her present family seems dysfunctional to a moderate degree. Joe was twenty years old when he started to date Carrie at only fifteen, and coupled with the physical abuse early in marriage, resistance to parenting equally, and his family's enmeshed approach with Carrie, there seems to be a dominance issue in their relationship. Emotional abuse is evident, including the threat to call child protective services on Carrie unless she met with me. Carrie feels that she has no privacy in Joe's enmeshed family, which includes the secretary at the family business as well as Joe's intimidating father. Her sister in law Maureen was told by Joe's father to move in to help with the children, but Carrie and Maureen ended up doing drugs together and had the same dealer. The family always sides with Joe, who shares even the most private details of their marriage with his family.

Carrie has a seven year old son, Joseph Jr. (JJ), whose imminent birth caused her to marry Joe despite misgivings. He has been diagnosed with ADHD, and his four year old sister Rachel appears to have it as well. Carrie's addiction and possibly the macho tendencies in Joe – she could hide her drugs in the diapers because he never performed the chore of changing either child. In any case, she is overwhelmed by her rambunctious children and has difficulty setting structure for them to help with the ADHD symptoms and provide a family routine.

Carrie is also apparently sexually preoccupied, having multiple affairs as well as sexually charged arguments with Joe in which they "make up" by having passionate sex. Joe suspects the infidelity but Carrie will not confirm it for fear of breaking up the marriage. She will not consent to couples or family therapy because she fears the issue will come up, even though those therapies might help unify the family more.

LEISURE/RECREATIONCarrie, who comes from a working class background, feels out of place in her upper class neighborhood and avoids forming relationships with neighbors. She does not have friends or family (except Joe and his dad) who don't use substances at this point in her life. Carrie feels confined as a stay at home mother but her lack of a high school diploma or GED severely limits her ability to get jobs. This may be part of the dominance issue in her marriage, since Joe instigated her high school dropping out. She has thoughts of leaving Joe, and they once separated, but the only work she could find was a cocktail waitress job, which paid next to nothing and certainly would not let her raise the children. It also gave her frequent opportunities to drink, if it was a typical tavern job. She does not want to lose custody of her children, which is likely if she divorces Joe given his superior ability to support them and lack of formal substance abuse history.

Carrie's recreation involves drinking, smoking marijuana, snorting cocaine and having sexual affairs with multiple men including her drug dealer in a sex-for-drugs prostitution arrangement. The drugs and drinking were expected and frequent events in her family of origin, which may influence her lack of a role concept without substance abuse involved. Her sister in law uses drugs with Carrie as well, despite Joe's family image of being straight and narrow abstainers. It is normative for mothers of young children to derive some of their leisure/recreation with them, but this does not appear to be the case for either Carrie, Joe or both together. There do not appear to be any family activities going on, or attendance of JJ's or Rachel's school events. It appears that alcohol and drugs provide Carrie's only respite from her stressful, chaotic and powerless life as an isolated stay at home mom without non-using friendships.

EDUCATION/EMPLOYMENTCarrie

LEGAL & MILITARY Carrie has no family or personal military background, and no she legal issues relating to substance abuse at least yet. Joe has threatened to turn her in to child protective services for neglect, and even if he doesn't, a divorce and custody battle seem likely.

DIAGNOSTIC DISCUSSIONCarrie is a 25 year old European American woman who presents today requesting substance abuse treatment following six months of daily powder cocaine use. She agreed to seek treatment because her husband Joe threatened to report her to child protective services for neglect of their children.

Carrie was clearly suffering from physiological withdrawal symptoms including moodiness and shakes from cocaine dependence (DSM 4R AXIS I 304.2). AXIS II was coded 799.9 Diagnosis Deferred, because Carrie functions very successfully socially when uninfluenced by substances and no signs of personality disorder were present. Axis III was also deferred because Carrie is apparently in good health, but she was referred to a medical doctor because her probable unsafe sex practices during prostitution and affairs, long term alcohol and drug use and physiological withdrawal from cocaine pose numerous health risks. The AXIS IV Diagnosis of Partner Relational Problems and Parent-Child Relational Problems reflects Carrie's addiction related hostility and anger in her relationship with Joe and impaired ability to care for and provide structure to her children JJ and Rachel. Therefore on AXIS V, Carrie seems to fall in the severely impaired Global Assessment of Functioning range of 45, compared with a GAF of 60 in the past year, before she added daily cocaine use to her pre-existing alcohol and marijuana use, which do not appear to rise to the level of dependence at this time.

I believe that Carrie has the strong motivation of potentially losing her children and the unpleasant withdrawal symptoms from cocaine. Carrie is admitted to residential treatment, but her insurance refuses to pay more than seven days. Since her family is wealthy they chose to self pay for the rest of the 30 day course of inpatient treatment. She plans to return to weekly individual therapy with me following her residential treatment. A summary of our mutually agreed on formal treatment goals at intake follow.

TREATMENT PLAN

The first priority is that Carrie has been referred to her primary care physician for an examination today, including her potentially lethal asthma with prescriptions written in the customary way. Carrie seems to be in the action stage in this area of treatment. The physician will also consider a prescription to treat depressive symptoms. The agency, with Carrie's written consent, will keep a copy of all prescriptions and pass any medication scheduled during program hours. There is no risk for HIV infections as Ms.O has been celibate by choice for many years and has tested negative every year for work. Our nurse will track respiratory signs daily and as needed, and therapists will assess Carrie for worsening depression daily. The possible role of depression in her recent relapse will be explored in itself, as well as along with other psychosocial factors. The second treatment priority addresses the psychosocial path from recovery to relapse and will focus on the substance abuse itself: to help Carrie identify possible triggers for this binge relapse. It appears that she is in the preparation stage and has recently had enough difficulty to produce relapse. She appears to be regrouping and making progress, recognizing the need for treatment and actually seeking it immediately is a positive sign. Initially it appears that depressed mood with less attention to self care and prevention, loosened standards for forming social ties and possibly an unusual vulnerability to known psychological and physiological addiction relapse triggers at work may be the major contributors. Carrie plans to explore these matters during individual and groups therapy.

The third main treatment goal is psychological: to restore Carrie's self esteem and self-confidence through individual and group treatment. She appears quite devastated emotionally by this relapse, although intellectually she recognizes it as part of an episodic illness. Carrie reported feeling discouraged, hypocritical and even incompetent in her professional addictions treatment provider role, which she highly values. These statements point to the contemplation stage, with a need to rebuild Carrie's confidence, self esteem and re-acceptance of existing strengths the goals that can move her toward emotional and physical addiction recovery. Obliquely assigning Carrie leadership roles in the educational portions of treatment may boost her confidence, and reinforcing her naturally emerging leadership role in groups will counter these false beliefs. Individually exploring relapse as a teacher and something that happens to virtually everyone with an addiction may help her accept the event emotionally and neutralize it.

The fourth goal employs Carrie's leisure time and activities, increasing time spent in her supportive, drug-free church activities and daily or more often 12 step group attendance with her few very close friends. Carrie stated that expanding her social circle too much contributed to her relapse because, "I'm attracted to bad people." She will identify strategies and implement a plan of strengthening positive leisure activities.

Carrie is supported by her employer socially and administratively by the 70% of her coworkers who are in addiction recovery themselves. She has an uncharacteristically accepting workplace where she can be open about the need for leave and the purpose. The only treatment issues here are to assist her in filing for FMLA and identify potential work triggers creating plans to manage them during vulnerable times of life.

With respect to Carrie's goal to earn and online Social Work Administration master's degree, exploration of her readiness to start and the effect of stress versus the stress relieving enjoyment of studying will be examined. It does not appear that education has triggered relapse in the past, but this issue still warrants exploration and setting up coping strategies.

Since Carrie has never served in the military and has not experienced legal issues for many years, these areas of treatment are deferred.

Carrie identified her religious faith creating a positive outlook, limiting her social circle to "safe" and trusted individuals including a few close friends, 12 step sponsors and her church family as supports in her recovery. She identified a tendency to be "attracted to bad people" and lack of power over addiction with any use at all as addiction triggers that may or may not be se t off at work. Carrie was open to identifying triggers and using behavioral methods to dampen or eliminate them.

I believe that Carrie's treatment prognosis is excellent. She is a professional substance abuse counselor, very educated and aware of the components of treatment. She was sober for 16 years before this relapse and comes to the program immediately following a four day relapse binge. Carrie is strongly motivated for change, has a deeply held personal faith and a drug-free church family for help, and attends 12 step programs daily. Given her quick action, insight, and willingness to participate in treatment, it seems likely that intensive outpatient therapy will resolve the issues surrounding this brief relapse. If the need emerges for more intensive treatment, Carrie is eligible for our residential treatment program.

This is just such a horrible accidental death. She probably just hit her head on her ski. Natasha Richardson was a brilliant actress and fine human being, and her death at such a young age leaving two sons to grow up without her is tragic.

I'm going to riff on some themes from not-good articles, so if anyone doesn't want to read that or might be triggered regarding brain death or emergency medicine please be warned. I'm distressed over coverage because of personal experience with my brother Mike's brain death in the 1980's, and I understand how these public articles and discussions can feel to read. :(

I had an absolutely identical accident in junior high, and the back of the ski gave me a concussion and dislocated 2 of my neck's vertabrae. I had an identical lack of symptoms, and my girl scout leaders were identically advised to take me to the ER and identically refused. For good reason - millions of falls like this happen every year, and only one person dies. It's tragic, but it was an ACCIDENT and nobody did anything wrong. This seems lost on many journalists and commenters - I feel like we've culturally completely lost the acceptance that some things are not in anybody's control, and sometimes there's just no cause to blame anybody. Nobody, least of all Natasha Richardson herself, could have prevented her death.

I hate the health moralism in many of the articles I've seen, "This goes to show she should have been wearing a helmet." or "This shows she should have gone to the hospital with no symptoms." or "it must be malpractice - see what socialized healthcare does." Also, the laughable American neurosurgeon saying "this is why we keep people with possible head injuries 24 hours for observation."

First, I can GUARANTEE that if she had shown up immediately in any US ER, she would've been told to take ibuprofen and discharged immediately with advice to come back if she started to stumble around or slur speech, NOT "kept 24 hours for observation." Her only prayer would have been a typical long wait, but once symptoms appear there's just so little time before brain surgery is futile that she still might not have lived. Most of the surgeons quoted even said so.

Starting when I was 21, my family had to watch my brain dead brother Mike linger for years with no hope of recovery because, "you can't sue us for 'saving his life' but you can for stopping treatment so we won't." (Direct quote from a hospital administrator to my grieving parents, may he burn in hell. But only for a bit, I'm a universalist agnostic, after all.)

Mike and I both had severe asthma, and after watching a movie on a "vegetable" swore a pact to kill each other if it ever happened to us, which frankly was not unlikely given our medical histories. We were maybe 13 and 12. And I didn't follow through on my promise to him, from a blend of cowardice and the knowledge that if I killed him as requested, my parents would just be agonized all over again.

And I can never forgive myself for breaking that promise.

I know intellectually today that I promised when I was too young to understand fully the promise made, and that we didn't regard anyone else's feelings when we made the pact, and even that because Mike was brain dead (presumably unaware) and my parents were not I probably made the "best" choice for everyone else involved.

And none of it changes the magnitude of my betrayal of the person I loved most in the whole world.

Because watching what happens to your brother when bean counters keep the dead artificially alive is disgusting and enraging to a degree that I'm not sure I can express. My funny, loving, cynical, brilliant and occasionally cruel little brother Mike's corpse was mutilated for years by people who swear to preserve health and life (albeit reluctantly by most of them). He was overdosed on antifebrile medications to force his brain stem to regulate body temperature, and steroids to keep him breathing so he couldn't die of an asthma attack. They bloated his body unrecognizably. Because he was brain dead he wasn't "eligible" for physical therapy and his muscles withered and contracted, contorting his limbs. He was often racked with coughing because of opportunistic viruses. I was really outraged when they gave my already dead brother TB treatment that some inner city kid it would actually save desperately needed and would never get because his parents were poor. A recurrence of TB and pneumonia at once finally allowed Mike the peace denied him for six years after his original death. He'd died again and been resuscitated at least 10 times in the interval, all against my parents' wishes.

At least we have laws now that allow families like Natasha Richardson's to stop medical interventions that keep a brain dead beloved family member from dying peacefully. The immediate grief and pain are no less, but I wouldn't wish the prolonged version on any mother's 12 and 13 year old sons. Truly there are things worse than death, but kids shouldn't have to know it.

If you don't have an advanced directive, I urge you to write one and give it to everyone in your family.